The moral burden of the itch: How historical stigma frustrates modern scabies control

“ They merely suck the blood or feed upon the feathers, scurf and desquamating epidermis. Hence they are termed “non-psoric” mites. A certain number of species, however, called in contradistinction “psoric” mites, give rise by their bites, by the rapidity of their multiplication, and by the excavation of galleries in the skin, to a highly contagious disease known as scabies or mange, which if not treated in time produces the gravest results. These mites belong exclusively to the Sarcoptidae and Demodicidae. ”

“ Scabies, or itch, is a contagious animal parasitic disease, due to the Sarcoptes scabiei, characterized by the formation of cuniculi, papules, vesicles, and pustules, followed by excoriations, crusts, and general cutaneous inflammation, and accompanied with itching. The amount of disturbance depends upon the duration of the disease and the sensitiveness of the skin. The itch mite (Acarus scabiei, Sarcoptes scabiei, or Sarcoptes hominis) through contagion finds its way upon the skin, and begins to burrow its way through the upper layers of the epidermis. ”

“ The male is smaller than the female, and in the adult condition the two hindmost legs have suckers, as well as the four anterior. It remains on the surface of the skin, while the female burrows deeply in the substance of the epidermis. At the bottom of the oblique burrow it deposits ten to fifteen or more eggs, which hatch in a fortnight and then commence similar operations on their own account. Scabies generally starts between the fingers, whence it rapidly spreads. The disease is acquired from some patient suffering from the disease, or by contact with his apparel. ”

“ It will not kill a full-grown bug under an hour, but it is extraordinarily effective with fleas. It is important to obtain a good pyrethrum powder, as such preparations are frequently adulterated.
The Itch Insect is the cause of the skin disease known as scabies. It is a mite, the female of which burrows under the skin to lay her eggs. The favourite site for her operations is between the fingers, but other parts of the body may be affected, and the rash produced may assume various forms, so that it is well in the case of any skin eruption in the tropics to remember the possibility of scabies. ”

“ It may be remembered also that the face and scalp, except in infants, are not involved. The multiform nature of the eruption is one of its prominent characteristics. It is a progressive disease. A history of contagion is often obtainable. It is to be distinguished from vesicular and pustular eczema and pediculosis. The more or less discrete vesicles and pustules of scabies, the localities affected, its progressive course, and the presence of burrows and a history of contagion will serve to differentiate from eczema. ”

“ In scabies the hands are almost invariably the parts first and most markedly involved. The characters of the lesions are also different.
The disease yields rapidly to proper treatment. Various remedies are employed for the destruction of the parasite and its ova. The most common, and one that is thoroughly efficient, is sulphur. It is usually prescribed in ointment, one to four drachms to the ounce. In irritable skins, or where the secondary dermatitis is marked, the weaker proportions are advisable. ”

“ The eruptions due to scratching have already been described in the descriptions of the ‘scratched skin,’ and comprise excoriations, erythema in parallel lines, eczema, impetiginous or so-called ecthymatous eruptions and wheals, and the inflammatory scab-topped papules often left after the subsidence of the wheals—especially in children. In carmen, cobblers, tailors, and others who sit on hard boards for hours together, pustular and scabbed eruptions, situated over the ischial tuberosities, are so abundant and constant as to be practically diagnostic of scabies in such people. ”

“ Female. Ventral surface. Male.
The disease is contagious to a marked degree, and is most commonly contracted by sleeping with those affected, or by occupying a bed in which an affected person has slept. It occurs, for obvious reasons, usually among the poor, although it is now quite frequently met with among the better classes. [Pg 270]
State the diagnostic features of scabies.
The burrows, the peculiar distribution and the multiformity of the eruption, the progressive development, and usually a history of contagion.
How do vesicular and pustular eczema differ from scabies? ”

“ In spite of this, however, we should designate as inhuman any one who, for this reason, would wish to wreak vengeance on the sick. In past ages, indeed, this was actually done: in primitive conditions of society, and even now among certain savage peoples, the sick man is treated as a criminal and as a danger to the community, and it is believed that he is the resting-place of certain demoniacal beings who have entered into his body as the result of some offence he has committed—those ages and peoples hold that the sick are the guilty! ”

“ From the point of view of society, any attitude of shame is unfortunate, because it is absolutely essential that these diseases should be met in the open and grappled with methodically and thoroughly. ”

“ At the Beginning of this Infection it can scarcely be distinguished, if a Person is not well apprized of its Nature; but in the Progress of it, the little Pustules increase both in Number and Size; and when they are opened by scratching, a loathsome kind of Scab is formed, and the Malady extends over the whole Surface. Where they continue long, they produce small Ulcers, and are at that Time highly contagious. ”

“ No; in those of great cutaneous irritability, especially in children, the skin being more tender, the type of the eruption is usually much more inflammatory. In those predisposed a true eczema may arise, and then, in addition to the characteristic lesions of scabies, eczematous symptoms are superadded; in long-persistent cases, indeed, the burrows and other consequent lesions may be more or less completely masked by the eczematous inflammation, and the true nature of the disease be greatly obscured. ”

“ It is painful to see the prevalence of such repulsive maladies as scabies, scald-head, ringworm, sore eyes, and unwholesome-looking eruptions, and fully 30 per cent of the village people are badly seamed with smallpox. ”

“ From the midst of this commonwealth of degradation there goes forth a moral contagion, scourging society in all its ramifications, coupled with an atmosphere of physical decay—an atmosphere reeking with filth, heavy with foul odors, laden with disease. In time of any contagion the social cellar becomes the hotbed of death, sending forth myriads of fatal germs which permeate the air for miles around, causing thousands to die because society is too short-sighted to understand that the interest of its humblest member is the interest of all. ”

“ I always recall with a shock the utterance of a university professor in the days when salvarsan was expected to cure syphilis at a single dose. He rated it as a catastrophe that any such drug should have been discovered, because he felt that it would remove a great barrier to promiscuous relations between men and women—the fear of venereal disease. This is the point of view that perpetuates the disease among us. It is this attitude of mind that maintains an atmosphere of disgrace and secrecy and shame about a great problem in public health and muddles our every attempt to solve it. ”

“ Think of syphilis as the wages of sin, as well-earned disgrace, as filth, as the badge of immorality, as a necessary defense against the loathesomeness of promiscuity, as a fearful warning against prostitution, and our advantage slips from us. The disease continues to spread wholesale disaster and degeneration while we wrangle over issues that were old when history began and are progressing with desperate slowness to a solution probably many centuries distant. Think of syphilis as a medical and a sanitary problem, and its last line of defense crumbles before our attack. ”

“ There is, no doubt, some force in the position that the non-licensing of these houses is in some degree a terror to the community, and that the cautious and prudent are kept from the offense through fear of possible consequences in disease and infection. This, however, does not seem to us an object which legislators can hold before them as compared with the duties of humanity in curing and preventing disease and pestilence. They have nothing to do with adding to the natural penalties of sin, or with punishing sinners. They are concerned only with human law. ”

“ The Broader Outlook.—If, then, it avails nothing in the uplifting of our morals to treat syphilis as a disgrace, if the disease is ineffective as a deterrent, and barbarously undiscriminating, inhuman, and unjust as a punishment, let us in all fairness lay aside the attitude of mind which has so hindered and defeated our efforts to deal with it as an arch enemy to human health, happiness, and effectiveness. ”

“ Yet it is an attitude which should not be ignored for it still carries weight with many who are too weak to withstand those who juggle with fine moral phrases. I have even seen in a medical quarter the statement that venereal disease cannot be put on the same level with other infectious diseases because it is "the result of voluntary action." But all the diseases, indeed all the accidents and misfortunes of suffering human beings, are equally the involuntary results of voluntary actions. ”

“ We who do not want to know, also do not want to go blind, to go mad, to be disfigured, to be barren, to become pestiferous, or to see such things happening to our children. We learn, at last, that the majority of the victims are not the people of whom we so glibly say, 'Serve them right,' but quite innocent children and innocent parents, smitten by a contagion which, no matter in what vice it may or may not have originated, contaminates the innocent and the guilty alike, once it is launched, exactly as any other contagious disease does ”

“ Under such circumstances, even if it were possible in a civilized community to leave misconduct to be checked by its natural or accidental consequences or by private vengeance instead of by carefully considered legal measures, such an anarchical solution must be ruled out in the present case, as the disease strikes blindly at everyone whom it reaches, and there are as many innocent paths for its venom as guilty ones. ”

“ What the public welfare requires is, as is now admitted, that these sick persons should be treated with a single eye to arresting the course of their disease, and restoring them as soon as possible to physical health. Moreover, as sickness is plainly, to an undefined extent, the result of bad environment—of overcrowding, insanitation, unwholesome food, polluted water, or injurious conditions of employment—it is important that it should be in the hands of an authority officially cognisant of this environment, and empowered to alter that which is producing the sickness. ”

“ Such injustices ought, as far as possible, to be prevented by the State.
The most obvious example of a matter where the general welfare depends upon a universal minimum is sanitation and the prevention of infectious diseases. A single case of plague, if it is neglected, may cause disaster to a whole community. No one can reasonably maintain, on general grounds of liberty, that a man suffering from plague ought to be left free to spread infection far and wide. ”

“ If we want to get rid of evil we must remove the cause of evil. It is useless to punish the victim.
It is with moral evils as with physical evils. When an epidemic of fever or smallpox comes upon us we do not punish the sick, nor blame them. But we isolate the sick, and we attack the cause of the sickness, by attending to matters of hygiene and sanitation. That is how we ought to deal with moral sickness.
Men do not live badly because they are "wicked," but because they are ignorant. The remedy lies in the study and adoption of the laws of the science of human life. ”

“ Sexual disease should be referred to, like all other sexual questions, as incidental to the whole subject of the body and its functions, abuses and diseases. The idea that any disease may justly be regarded as a fitting "punishment" for any particular crime, is as evil in its effect as it is vicious in its principle. To encourage the notification of every disease, especially the worst, is a public duty we can only evade at enormous cost in innocent lives. ”

“ Among us, no public agency is formally charged with any duty in the matter of preventing, recognizing, or treating the vast amount of venereal infection that mars our national health. Certain state boards of health are attempting to perform Wassermann tests, and certain municipalities have well-organized laboratories for the detection of syphilis and gonorrhea, but there are few purely public agencies that even pretend to have a specialist in their employ to assist in the recognition of cases and conduct the treatment of patients who cannot afford private care. ”

“ The medical profession, hitherto divided in opinion as to the feasibility of such undertakings, is virtually united in the conclusion that so long as commercialized vice exists, physicians cannot guarantee a city against the spread of the contagious poison generated by it, which is fatal alike to the individual and to his offspring. The medical profession agrees that, as the victims of the social evil inevitably become the purveyors of germ diseases of a very persistent and incurable type, safety in this regard lies only in the extinction of commercialized vice. ”

“ The medical profession is at last taking the position that the community wishing to protect itself against this contagion will in the end be driven to the extermination of the very source itself. A well-known authority states the one breeding-place of these disease germs, without exception, is the social institution designated as prostitution, but, once bred and cultivated there, they then spread through the community, attacking alike both the innocent and the guilty. ”

“ We leave innumerable populations steeped in misery, seven or eight individuals living in the same infected hovel. In the slums of our large cities, swarms of infants are to be found morally and materially perverted by misery. Therefore, if consumption still exists, it is our own fault; it is no longer as it was in olden times, when we knew not, because now we know. The plague can be battled with; and if it still has so much power left, it is because we have not the courage to apply to public and individual hygiene the treatment science has definitely shown us should be applied. ”